General Info

Windsor Rx is a Part D Prescription Drug Plan, which is a product of Windsor Health Plan, Inc. Windsor Health Plan, Inc., has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare, to provide Medicare prescription drug coverage to Medicare beneficiaries within our approved service areas. (To see complete service area and benefits information for all Windsor plans go to http://www.WindsorExtra.com.) One way for Medicare beneficiaries to receive prescription drug coverage is to stay with Original Medicare and enroll in a stand-alone Medicare Prescription Drug Plan (PDP).

When to enroll:
The Initial Enrollment Period for Part D (IEP for Part D) is the period during which you are first eligible to enroll in a Part D plan. In general, an individual is eligible to enroll in a Part D plan when he or she is entitled to Part A or enrolled in Part B, and permanently resides in the service area of a Part D plan. Individuals eligible for Medicare prior to age 65 (such as for disability) will have another Initial Enrollment Period for Part D based upon attaining age 65.

Open Enrollment:
Each year Medicare provides an open enrollment period so beneficiaries can switch plans or sign up for the first time. The open enrollment time frame is from November 15 to December 31, every year.

Can anyone enroll?
If you are enrolled in a Medicare Advantage (MA) coordinated managed care plan (HMO or PPO) or an MA private fee-for-service (PFFS) plan that includes Medicare prescription drugs, you may not enroll in a stand-alone PDP unless you disenroll from the HMO, PPO, or PFFS plan. Enrollees in a PFFS plan that does not provide Medicare prescription drug coverage, or an MA Medical Savings Account (MSA) plan, may enroll in a PDP. Enrollees in an 1876 Cost plan may enroll in a PDP.

If you join the Windsor Rx stand-alone drug plan, you may still keep your Original Medicare. Another choice you have is to join a Medicare Advantage and Prescription Drug (MA-PD) Plan offered by Windsor Medicare Extra for all of your medical and prescription drug needs. You can learn more about these plans at http://www.windsorextra.com, or call us at 1-800-316-2273 (TTY for the hearing impaired 1-866-460-7617) from 7:00 a.m. to 8:00 p.m. Central Time, 7 days a week.

You can also contact Medicare for more information at http://www.medicare.gov on the web, or call 1-800-MEDICARE (1-800-633-4227) (TTY users should call 1-877-486-2048.).

You were also sent a booklet by mail called "Medicare and You". This booklet tells you about the different choices you have to receive your Medicare medical and prescription drug benefits.

If You Have Employer or Union Prescription Coverage:
If you have prescription drug coverage from a former or current employer or union, contact your benefits administrator before you make any changes to your drug coverage. If you join a Medicare Prescription Drug Plan or Medicare Advantage Plan, you and your family may lose your employer or union coverage.

Methods for enrolling into Windsor Rx:

  • You must complete a Windsor Rx enrollment form and mail it to us, or;
  • Enroll online on the Windsor website, or;
  • Enroll through Medicare by calling 1-800-MEDICARE (1-800-633-4227) or toll free at 1-800-633-4227; (TTY/TDD users call 1-877-486-2048), 24 hours-a-day, 7 days-a-week; or go to the Medicare website: http://www.medicare.gov, or;
  • Enroll by phone with a Windsor enrollment counselor, or;
  • Have a legal authorized representative enroll you through one of the above methods.

Even if you are enrolled in one Windsor plan and you are electing another Windsor plan, you must complete a new enrollment election. Call us at 1-800-316-2273 (or TTY for the hearing impaired 1-866-460-7617) from 7:00 a.m. to 8:00 p.m. Central Time, 7 days a week and we can send you the appropriate plan-to-plan enrollment form.

Once Windsor receives notice from Medicare we will send you a notice of confirmation of enrollment, rejection of enrollment, or a denial of enrollment and the reason.

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What drugs does the Windsor Rx plan cover?
Windsor Rx has a list of covered drugs called a formulary. Our formulary includes at least two drugs (and in some cases all drugs) in all classes of drugs most commonly prescribed to people with Medicare. This makes sure that people with different medical conditions can get the treatment they need. The list can change during the year because drug therapies change, and new drugs and medical knowledge become available. If you are affected by the change, your plan will notify you at least 60 days before the formulary changes. If there is a formulary change that affects a drug you take, in most cases it will still be covered for you until the end of the year.

Be sure to look over your current prescription drug coverage and ask yourself the following questions:

  • Are prescription drugs covered?
  • Are my prescription drugs covered?
  • What are the out-of-pocket costs?

What pharmacies can I go to?
Windsor Rx provides prescription drug benefits through Medicare-certified pharmacies. Windsor Rx has an extensive list or directory of network pharmacies. This list is posted on this website. It is also mailed to you when you become a Windsor Rx member. A network pharmacy is a pharmacy where beneficiaries obtain prescription drug benefits provided by Windsor Rx. In most cases, your prescriptions are covered under Windsor Rx only if they are filled at a network pharmacy or through our mail order pharmacy service. Once you go to a pharmacy, you are not required to continue going to that same pharmacy to fill your prescription. You can go to any of our network pharmacies. To get current information about the Windsor Rx network pharmacies in your area, please visit our website at http://www.WindsorRx.com, or call our Customer Service department at 1-800-264-1587, 24 hours day, seven days a week (TTY/TDD users should call 1-800-595-8856.).

To find a pharmacy near you in the pharmacy directory, you should first locate the type of pharmacy you need. The three types of pharmacies include retail, mail order and long-term care. The directory is then arranged in alphabetical order by county, then by city, and finally then by zip code. We have also indicated if the pharmacy is open 24 hours a day. Or, you can visit our website at http://www.WindsorRx.com or call Customer Service at 1-800-264-1587, 24 hours day, seven days a week (TTY/TDD users should call 1-800-595-8856.).

Mail order:
We also offer a mail-order program that will allow you to have drugs sent directly to your home. To get order forms and information about filling your prescriptions by mail, contact CVS/Caremark by phone at 1-800-264-1587, or by fax at 1-877-889-3403. Please note that you must use the Windsor Rx mail order service. Prescription drugs that you get through any other mail order service are not covered.

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Getting Help Paying for the Costs of Prescription Drug Coverage:
If you have Medicare and have limited income and resources, you may qualify for extra help paying for prescription drugs. The low income subsidy is extra help with prescription drug costs for Medicare-eligible individuals whose income and resources are limited. This help is in the form of payments to the Part D Plan that you join. Persons eligible for Medicaid, Supplemental Security Income (SSI), or a Medicare Saving Program qualify for the extra help automatically and do not need to apply. All others may apply with the Social Security Administration (SSA) by mail, by telephone, on the Internet at http://www.socialsecurity.gov or in person at a community event or an SSA office. Applications may also be filed at a local Medicaid office.

Beneficiaries can also access the Medicare web site for requirements for the low income subsidy: http://www.cms.hhs.gov/States/03_lowincomesubsidy.asp, or call the Medicare Service Center at 1-800-MEDICARE (1-800-633-4227) TTY Toll-Free: 1-866-226-1819.

Are my drugs covered?
A formulary is a list of drugs selected by Windsor Health Plan, Inc., for coverage by our Windsor Rx plan. This formulary is reviewed and approved by Medicare. Windsor Rx plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Windsor network pharmacy, and other plan rules are followed. Windsor may add or remove drugs from the formulary during the year. We will provide 60-day notice regarding removal or change in the preferred or tiered cost-sharing status of a Part D drug.

Appeals & Grievances:
Members of Windsor Rx have the right to appeal any decisions we make related to prescription drug benefits, including but not limited to a denial, termination, payment or reduction of services. For more information on the grievance and appeal process, contact Windsor Rx Customer Service at 1-800-264-1587 (TTY for the hearing impaired 1-800-595-8856) 24 hours a day, seven days a week. You can also access the grievance and appeal process on this website. Simply click on the icon for Appeals & Grievances.

Quality Improvement Program:
Windsor Health Plan, Inc., is dedicated to administering benefits to our Windsor Rx plan members effectively and efficiently. We are committed to providing our members access to high quality, comprehensive and cost effective medical care. The intent of Windsor Health Plan’s Quality Improvement Program is to support contracted providers in order to continually improve the quality and cost effectiveness of services provided to Windsor Rx plan members, and to support the effective and efficient administration of covered benefits. The scope of the Quality Improvement Program encompasses the populations covered by the Windsor Rx plan and is comprehensive, spanning the full range of clinical and health administrative services provided to all members.

Medication Therapy Management Program:
Windsor Health Plan, Inc., recognizes the importance of monitoring medications to prevent potential adverse events and establishing best practice outcomes. Our plans have a Medication Therapy Management Program that is designed to be patient focused, aimed at improving therapeutic outcomes and identifying best practices. This process will involve a Medication Therapy Management Team consisting of pharmacy, case management, disease management, customer service, provider relations and utilization management staff with oversight provided by the Chief Medical Officer. The program consists of identifying beneficiaries who are eligible for the program and communicating with the member and providers, developing interventions, promoting educational opportunities and working directly with the member to help them improve their health related outcomes.

What is "Disenrollment"?
"Disenrollment" from your Windsor Rx plan means ending your membership in your Windsor Rx plan. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice.) The first step is to be sure that the type of change you want to make and when you want to make it fit with the rules about election periods. If the change does not fit with these rules, you won't be allowed to make the change. Remember, there are limits to when you may leave, how often you can make changes, and what type of plan you can join after you leave.

There are also a few situations where you would be required to leave. Some of those situations are listed below:

  • If you do not stay continuously enrolled in Medicare Part A or Medicare Part B.
  • If you give us information on your enrollment form that you know is false or deliberately misleading, and it affects whether or not you can enroll in your Windsor Rx plan.
  • If you behave in a way that is disruptive, to the extent that your continued enrollment seriously impairs our ability to arrange or provide medical care for you. We cannot make you leave your Windsor Rx plan for this reason unless we get permission first from the Centers for Medicare & Medicaid Services, the government agency that runs Medicare.
  • If you let someone else use your plan membership card to get medical care. If you are disenrolled for this reason, CMS may refer your case to the Inspector General for additional investigation.
  • If you do not pay your applicable plan premiums, we will tell you in writing that you have a one (1) month grace period during which you can pay the plan premiums before you are required to leave your Windsor Rx plan.

No member of any Medicare health plan can be asked to leave the plan for any health-related reasons. If you ever feel that you are being encouraged or asked to leave your plan because of your health, you should call 1-800-MEDICARE (1-800-633-4227), which is the national Medicare help line. TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.

You have the right to make a complaint if we ask you to leave your Windsor Rx plan.

Whether leaving the plan is your choice or not, until your membership ends, you must keep getting your Medicare services through your Windsor Rx plan pharmacies or you will have to pay for them yourself. The exceptions are urgently needed care, care for a medical emergency, out-of-area renal (kidney) dialysis services, and care that has been approved by us.

How to Disenroll:
First, use any of the following ways to tell us that you want to leave your Windsor Rx plan:

  • You can enroll in another plan (during a valid enrollment period).
  • You can write or fax a letter to or fill out a disenrollment form and send it to Windsor Rx, Attention: Enrollment at 7100 Commerce Way Suite 285 Brentwood, TN 37027 or to our fax number at 1-615-782-7986. Be sure to sign and date your letter or form. To get a disenrollment form, call our Customer Service department at 1-800-264-1587. TTY users should call 1-800-595-8856.
  • You can call 1-800-MEDICARE (1-800-633-4227), which is the national Medicare help line. TTY Users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.

We will then send you a letter that tells you when your membership will end. In most cases, your disenrollment date will be the first day of the month that comes after the month we receive your request to leave.

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Important Contacts:

Centers for Medicare and Medicaid Services (CMS)
7500 Security Blvd.
Baltimore, MD 21244-1850
1-800-633-4227, TTY: 1-877-486-2048.
24 hours a day, 7 days a week.

Medicare
1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users call 1-877-486-2048.
http://www.medicare.gov

Social Security Administration
6401 Security Blvd.
Baltimore, MD 21235
1-800-772-1213, TTY: 1-800-325-0778.
7 a.m. - 7 p.m.
http://www.ssa.gov/

SHIIP - Seniors Health Insurance Information Program

Tennessee:
Commission on Aging and Disability
1-877-801-0044,
TDD: 1-615-532-3893.

Arkansas:
Seniors Health Insurance Information Program
Arkansas Insurance Department: 1-800-224-6330

Alabama:
SHIIP Office: 1-800-243-5463

Mississippi:
MS Insurance Counseling and Assistance Program:
1-800-948-3090
1-601-359-4929

South Carolina:
Insurance Counseling Assistance and Referrals for Elders (I-CARE):
1-800-868-9095

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